Ramblings of an Emergency Physician in Texas

ER Overcrowding: View from the Outside

I guess they just got their journals, but this week both DB’s Medical Rants and Notes from Dr. RW have decided to denounce the Institute of Medicines’ recommendations to help ease ED overcrowding, specifically the IOM’s recommendation (poorly worded, IMHO) to “…achieve this goal by adopting operations-management techniques and related strategies to enhance efficiency and improve patient flow.” Kevin, MD calls this an “asinine tactic”.

Essentially, they don’t think this is a workable solution to easing ED overcrowding. Dr. RW doesn’t actually give a solution, but DB does:

The solutions are all economic. We need better access for health care outside of ERs. We can only get that if we fund primary care better and subspecialties less well. We need to recognize the importance and difficulty of delivering excellent primary care.

The lack of adequate reimbursement for primary care (relative to subspecialties) leads to serious externalities on our system. But then, do we really have a system?

Uh, huh. No, we don’t have a system, we can agree there.

A few things. First, people who are being admitted to the hospital cannot be cared for in the internists’ office. If they could, we’d gladly send them there. I know how the argument goes: if we could just get more people funded for primary care, they wouldn’t get sick as often, and admissions would go down. Sounds great, but I sincerely doubt it works that way with an aging population. Most of the ill patients I admit have seen internists, are taking their 3-20 medicines, and still need to come into the hospital. Add in the monkey-with-a-gun and fear of missing anything, and patients will be admitted.

Second, what’s so magic about the ED? Only the ED and OB have rubber walls and are infinitely flexible, to try our best to care for every patient ho needs our help. Except, see, our walls really aren’t made of magic rubber, we can’t just snap our fingers and make more rooms, beds, monitors or nurses appear. Every patient who should be admitted to the hospital but isn’t is a) not getting the specialized nursing care available on the ward where they belong and b) is taking up a bed in the ED we need to see then next 1-12 patients. The linked commenters in the first paragraph give a ‘suck-it-up ED’ subtext that rankles. We’re doing that.

To make things worse, our county drank the potion and decided none of the ED’s would go on diversion for medical cases unless an internal disaster was invoked (and it’s not easy: it involves waking the VP’s, etc). What that means from an operational standpoint is a never-ceasing tide of patients, and now permanently occupied hallway beds, and since we don’t have that many rooms, we have a lot of hallway beds. Sick people in hallway beds, because we don’t have enough room, or rooms.

Lastly, I know that ‘hallway protocols’ to put admitted patients into ward hallway beds work. We started it at our joint last year (about the time we stopped ambulance diversion), and we found some amazing things (predicted by the consultants from places that had done it before us): tell a ward they’re getting a hall patient, and magically a bed opens up on their ward, someone already dismissed but the bed status hadn’t changed. When there really are no rooms on the ward, each ward gets exactly one hallway patient. You only need to move hallway patients to about 10 wards and it has a tremendous positive impact on our flow in the ED, and from the feedback the extra workload isn’t that great on the nurses upstairs. (There are very strict criteria for hallway patients: no ICU, not too sick, etc).

So, fellows, while it’s just a temporizing measure, the IOM recommendation works, for now. I expect the numbers of patients requiring admission to go up, not down. We all await your workable solution to today’s problem.

Comments

As an ED nurse, what you say rings incredibly true. An important “middle ground” I think both pieces miss is the effect of those coming to the ED for primary care. Not the elderly polypharmacy patients that are still sick, but the people who, due to lack of insurance, (or in our case in Arizona) lack of legal resident status, have no primary care. So they clog up or ED with “My baby has a fever” or “I have a sore throat”. Yes, they sit in the waiting room while more sick patients come through, but they still take up time and resources we don’t really have. There was an interesting article in our local newspaper that I wrote about yesterday that showed in a one year study, 46% of Arizona ED visits were for non-emergency issues. If we could reduce that number by half, think of the increase in patient flow we could achieve…

Reducing the nonemergent visits wouldn’t really improve flow as much as you think. This is one of the biggest myths out there. The people with sore throats and febrile toddlers don’t occupy monitored beds. They don’t take up very much doctor time, and most importantly the only thing they really need (as opposed to what they may want) the nursing staff to do is periodically eyeball them to make sure they haven’t gotten sick. This is a very different situation than a nonambulatory patient with iv antibiotics and analgesics running, let alone an unstable patient on inotropes. I really do feel that once a patient has been admitted, they need to get out of the ED ASAP. If the ward/ICU really can’t take them, then the attending for the ward should take the responsibility of getting them a bed somewhere else.
In our community, the backup of admitted patients in the ER is literally spilling into the street, since when the ER is full, EMS is not permitted to leave their patients in the waiting room. Last week we briefly had ONE ambulance crew out on the streets to serve a population of one million. The rest of the crews were sitting in the ER doing crossword puzzles beside the patients they couldn’t leave, because all the ER beds were taken by admitted medicine/surgical patients waiting for beds on the wards…

Thank you Dr grunt.
Your comments ring so true and come as our own department battles new lows of overcrowding, access block and all the accompanying erosions of our doctors ability to deliver quality emergency medicine.
Even my own solution seems slightly less than satisfactory.(http://impactednurse.com/?p=148)
And with our own cities population rapidly ageing, it is only going to get worse.

I’ve seen two groups up here that make me think you’re right. There are several free standing ED’s up here. They are basically level 2 ED’s with nothing else. They do a lot of primary type care. Lotsa physician time used. They’re not what takes up bedspace though. You get them in and out fairly quickly. The problem is bed space in the hospitals. It’s like the old saying that the fastest way to make planes run on time in Austin is to build another runway at O’Hare in Chicago, since everything runs through Chicago. More wards/floors/ICU’s would reduce ED strain. Maybe not ED physician strain (you still gotta see ’em), but system strain because the patients could get out.

This is a multifaceted problem, and therefore requires a multifaceted solution. And there isn’t (right now) the mechanism(s) to deal with it.

1. There is the problem of patients in the ED who don’t need the ED. They could go to a late hours clinic, many could wait to see their primary MD. The challenge is sifting them out, and saying, “Go someplace else.”

2. In many cases patients cannot get into the hospital because there is no concerted effort to get others out. Patients stay in the ICU because there are no monitored beds in a step-down unit, those patients stay there because there are no beds on the regular floors. Or because the attendings can’t handle their own anxieties. I always find it a little schizophrenic when doctors insist on patients staying on a monitored unit until some magical time when suddenly they go home! One moment, “We’re so worried you need to stay fully monitored,” then next, “Ok, you can go home now.”
Many patients stay in the hospital because there is no option for close outpatient followup — being seen daily or every other day — even though that could save a LOT of money all around.

3. In the ED, there are patients who need to be admitted, it’s obvious, but we have to do this ungodly complete workup BEFORE they can be admitted to the floor. I’ve overheard hospitalists getting upset with the ED doc when the entire workup for a problem wasn’t almost completely done before the patient left the ED.

4. Yes, there are a lot of patients in the ED without insurance, but for others, the ED is BIG business — premium prices on everything (if you can pay).

In the end, there is no concerted effort to work on these multiple facets of the problem, which really requires MDs to be in charge and doing something about these issues, not high-school graduate clerks as “discharge planners” or social workers or non-MD hospital administrators or some elderly semi-retired physician working bankers hours attending some meetings and shuffling papers around.

The mega workup the hospitalists request prior to admission is definitely one of the factors that clogs up our ER. “Get the CT scan and call me back.” Three hours later….yes, indeed, it really is diverticulitis.

I often wonder though, what would happen if wishes were granted and patients started going to their PCP, or to urgent care centers instead of the ED.
Someone is going to get the bright idea of “Look at all of the wasted space in the ED. We could put offices there!”
And you’re back to over crowded with the ability to treat less patients because the cash flow is what’s most important (right or wrong).

I am a board certified ER doc, and recently left full time ED practice and started working in a high end urgent care. What a difference! The good ED patient come to the urgent care and actually are happy and pay their bills. It is a beautiful thing!I diagnosed a women’s son with Lyme disease last week and she brought me a rum cake a few days later(got a headache after that shift). There is currently no health care system just a fragmented buch of hospitals and clinics leaving patients without a clue of how to get the best care, hoping to get a good primary care physician to guide them along. Our specialty of Emergency Medicine highlights most of American Medicine’s problems of today and I do not see much light at the end of this tunnel at this time, especially concerning out liaility crisis.

The mega workup the hospitalists request prior to admission is definitely one of the factors that clogs up our ER. “Get the CT scan and call me back.” Three hours later….yes, indeed, it really is diverticulitis.

This topic was discussed at length at Dr. Tony’s blog several months ago. I think both ED docs and hospitalists have a point, and both tend to push the envelope (in opposite directions) of what constitutes an adequate workup, especially if they’re busy.

On a different topic, I do primary care now and it drives me nuts when patients go the ED for non-emergent problems when I’m in my office. It’s a heck of a lot cheaper for them to come to see me plus the wait is almost always much less.

There has always been stress around the relative income of specialists vs primary care. Who works harder, who took longer to get there etc ad nauseum. Whereas I don’t disagree with the idea of increasing reimbursement to primary care docs, I have a hard time agreeing that it must in some way be hand in had with reductions to specialists. Surgery reimbursement, for example, is already at much less than half of what it was a few years ago. Cutting doctor pay has been about the only consistent method of healthcare cost control, and the turnip has pretty much been bled dry. And, at the risk of offending my primary care colleagues, there’s no way I can be convinced that their work is as hard or as time-consuming — as all consuming — as mine was. Perhaps we’ll agree at some point, when there’s no money left as the current deficits become incurable, that the only health care that’s cost effective is preventative, and we’ll get rid of surgeons altogether. It would have less impact on the health of our country than if we got rid of refuse removers. But until a decision like that is made, you’ll never see enough people choosing certain specialties — especially surgical ones — if the work isn’t reimbursed at a higher rate than that of primary care. I think it’s safe to say that’s a truism, right or not.

Look… specialties that require longer training, entail higher risks and sicker patients should be reimbursed at a higher rate. There has to be some return for the added education, stress, and liability, and in our current system that reward is financial. I don’t know too many people who would disagree with that.

However, physician pay is only a very small part of the healthcare pie, but it makes a nifty class-warfare and envy issue for people with political agendas. It’s the flip side of that old soak-the-rich coin that gets played over and over and over…

As someone who trained in the mid-80’s, just in time for the DRGs & that new pesky disease, AIDS, I’ve had expeience with the joys of hall beds. I’ve coded folks in hall beds. I’ve seen hall bed folks trying to use the commode. This is NOT something you’d want for your near & dear.

I now work out of a hospital where you can no longer direct-admit a patient, due to the paucity of beds. If I suspect that the person may need admission, I must send them to the ER. It has been years since I can pick up the phone & direct-admit a sickie from my office. They opened a whole new wing, with all those lovely new beds. Strangely, the admission process hasn’t eased one iota. But then, they’ve closed several hospitals in town. Gee, do you think there may be a connection?